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People use the internet as a primary source for learning about medical procedures and their associated safety profiles and risks. Although abortion is one of the most common procedures worldwide among women in their reproductive years, it is controversial and highly politicized. Substantial scientific evidence demonstrates that abortion is safe and does not increase a woman’s future risk for depressive disorders or infertility. The extent to which information found on the internet reflects these medical facts in a trustworthy and unbiased manner is not known.
The purpose of this study was to collate and describe the trustworthiness and political slant or bias of web-based information about abortion safety and risks of depression and infertility following abortion.
We performed a cross-sectional study of internet websites using 3 search topics: (1) is abortion safe?, (2) does abortion cause depression?, and (3) does abortion cause infertility? We used the Google Adwords tool to identify the search terms most associated with those topics and Google’s search engine to generate databases of websites related to each topic. We then classified and rated each website in terms of content slant (pro-choice, neutral, anti-choice), clarity of slant (obvious, in-between, or difficult/can’t tell), trustworthiness (rating scale of 1-5, 5=most trustworthy), type (forum, feature, scholarly article, resource page, news article, blog, or video), and top-level domain (.com, .net, .org, .edu, .gov, or international domain). We compared website characteristics by search topic (safety, depression, or infertility) using bivariate tests. We summarized trustworthiness using the median and IQR, and we used box-and-whisker plots to visually compare trustworthiness by slant and domain type.
Our search methods yielded a total of 111, 120, and 85 unique sites for safety, depression, and infertility, respectively. Of all the sites (n=316), 57.3% (181/316) were neutral, 35.4% (112/316) were anti-choice, and 7.3% (23/316) were pro-choice. The median trustworthiness score was 2.7 (IQR 1.7-3.7), which did not differ significantly across topics (
People seeking information about the safety and potential risks of abortion are likely to encounter a substantial amount of untrustworthy and slanted/biased abortion information. Anti-choice sites are prevalent, often difficult to identify as anti-choice, and less trustworthy than neutral or pro-choice sites. Web searches may lead the public to believe abortion is riskier than it is.
The internet is the first source the public turns to for medical information [
Despite these facts, many antiabortion arguments rest on misinformation regarding the safety and health consequences of abortion [
This cross-sectional study had two phases: first, we created a database of websites from searches about abortion and safety, depression, and infertility; second, we used the ecosystem database that we created to classify websites in terms of content trustworthiness, political slant on abortion, type of site, and top-level domain.
We utilized several steps to create our website database in order to minimize bias and most broadly capture what the general public would encounter while searching on the web (
Workflow of website selection for the analysis.
Circular dendrogram of unique websites found in the analysis. The center depicts the 3 keywords used to identify the most commonly searched terms for those topics, the middle ring includes the search phrases that were used for the Google search, and the outer ring depicts the URL search results for each search phrase.
We next classified and rated each website in the database. We rated websites on 5 metrics: (1) slant, (2) slant clarity, (3) trustworthiness, (4) type, and (5) domain. For slant, a website was determined to have a pro-choice or anti-choice bias if either (a) information was given in a biased or dramatic fashion (eg, an anti-choice site describing the procedure as “tearing the baby from the womb”), or (b) the website displayed an opinion regarding the provision of abortion and its legality (eg, a pro-choice site stating that abortion should be free and legal for all women); otherwise, the website was considered neutral. We assigned a slant clarity rating based on how easy it was to discern the website’s slant (obvious, in-between, or difficult/can’t tell). We scored trustworthiness on a rating scale from 1 to 5, with 5 being most trustworthy based on factors including the content and the source of the content (eg, creators, references, or affiliation with health care organizations or health care professionals) [
First, we created a visualization of the websites and their parent search terms and topics using RAWGraphs. Next, we compared website characteristics overall and by search topic (safety, depression, or infertility) using Pearson chi-square test or Fisher exact test for all categorical classifications to compare characteristics across topics. We summarized trustworthiness, measured on a 5-point scale, using the median and IQR. For each search topic, we also assessed the distribution of websites based on the content’s slant for the 5 query terms, and then compared the trustworthiness of query term results using Kruskal-Wallis and Wilcoxon rank sum tests. We used box-and-whisker plots to visually compare trustworthiness by slant and by domain type. Finally, we tabulated websites according to their slant and slant clarity, comparing distributions using Fisher exact test, and then used a bar graph to examine website counts graphically. The study was reviewed and approved by the Oregon Health and Science University’s institutional review board and was deemed not human subjects research.
After removing duplicates, our search methods yielded a total of 111, 120, and 85 unique sites for safety, depression, and infertility, respectively.
We found that the median score for trustworthiness of the websites was 2.7 (IQR 1.7-3.7), which did not differ significantly across topics (safety: median score 3.0, IQR 1.7-3.7; depression: median score 2.3, IQR 1.7-3.7; infertility: median score 2.7, IQR 1.7-3.7;
Website characteristics by search topic (n=316).
Characteristic | Overall | Safety (n=111)a | Depression (n=120) | Infertility (n=85) | |||||||
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<.001 | ||||||
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Pro-choice | 23 (7.3) | 17 (15.3) | 4 (3.3) | 2 (2.4) |
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Neutral | 181 (57.3) | 50 (45.1) | 65 (54.2) | 66 (77.7) |
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Anti-choice | 112 (35.4) | 44 (39.6) | 51 (42.5) | 17 (20.0) |
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.002 | ||||||
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Obvious | 121 (38.3) | 41 (36.9) | 49 (40.8) | 31 (36.5) |
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In-between | 125 (39.6) | 49 (44.1) | 33 (27.5) | 43 (50.6) |
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Difficult/can’t tell | 70 (22.1) | 21 (18.9) | 38 (31.7) | 11 (12.9) |
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.002 | ||||||
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Commercial (.com/.net) | 154 (48.7) | 45 (40.5) | 60 (50.0) | 49 (57.7) |
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International | 42 (13.3) | 8 (7.2) | 17 (14.2) | 17 (20.0) |
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Education (.edu) | 5 (1.6) | 2 (1.8) | 1 (0.8) | 2 (2.4) |
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Government (.gov) | 14 (4.4) | 8 (7.2) | 4 (3.3) | 2 (2.4) |
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Organization (.org) | 101 (32.0) | 48 (43.2) | 38 (31.7) | 15 (17.7) |
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.007 | ||||||
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News article | 30 (9.7) | 12 (11.3) | 13 (10.8) | 5 (5.9) |
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Forum | 17 (5.5) | 2 (1.9) | 2 (1.7) | 13 (15.3) |
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Blog | 16 (5.1) | 5 (4.7) | 8 (6.7) | 3 (3.5) |
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Feature | 63 (20.3) | 21 (19.8) | 20 (16.7) | 22 (25.9) |
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Scholarly article | 25 (8.0) | 9 (8.5) | 11 (9.2) | 5 (5.9) |
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Resource page | 158 (50.8) | 57 (53.8) | 64 (53.3) | 37 (43.5) |
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Video | 2 (0.6) | 0 (0) | 2 (1.7) | 0 (0) |
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Trustworthiness, median (IQR) | 2.7 (1.7-3.7) | 3.0 (1.7-3.7) | 2.3 (1.7-3.7) | 2.7 (1.7-3.7) | .409 |
aFive websites in the safety category were missing data about page type.
Box-and-whisker plots comparing trustworthiness of online abortion resources by slant and domain type (n=316). Trustworthiness was scored on a scale of 1 (least trustworthy) to 5 (most trustworthy). The central line in each box marks the median trustworthiness score; upper and lower box edges mark the 75th and 25th percentile, respectively; whiskers indicate 150% of the interquartile range and outliers are shown as individual points. Int’l: international domain (eg, .uk, .nz, .id).
We also examined our results using specific search query terms and noted that for searches on safety and infertility, trustworthiness scores were significantly different across query search terms (
Finally, we found that slant clarity, or how difficult it was to discern the anti-choice, neutral, or pro-choice slant of a website, varied significantly both by topic and by slant. In regard to the topic, there were many more depression websites with a “difficult/can’t tell” slant compared with sites about safety and infertility (31.7% versus 18.9% and 12.9%, respectively;
Search query terms used and associated trustworthiness and website slant for each search topic.
Topic and search query terms | Total, n (%) | Pro-choice, n (%) | Neutral, n (%) | Anti-choice, n (%) | Trustworthiness, median (IQR) | ||||
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<.001 | |||
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Abortion health risks | 19 (17.1) | 1 (5.3) | 7 (36.8) | 11 (57.9) | 2.3 (1.7-3.3) |
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Effects of abortion | 24 (21.6) | 0 (0) | 10 (41.7) | 14 (58.3) | 1.7 (1.0-3.0) | ||||
How safe is abortion? | 27 (24.4) | 5 (18.5) | 21 (77.8) | 1 (3.7) | 3.7 (3.0-4.3) | ||||
Risks of abortion | 23 (20.7) | 0 (0) | 6 (26.1) | 17 (73.9) | 1.3 (1.0-2.3) | ||||
Safe abortion | 18 (16.2) | 11 (61.1) | 6 (33.3) | 1 (5.6) | 3.7 (3.7-4.3) | ||||
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.143 | |||
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Abortion depression | 28 (23.3) | 0 (0) | 17 (60.7) | 11 (39.3) | 3.2 (1.7-3.7) |
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Abortion recovery | 29 (24.2) | 0 (0) | 14 (48.3) | 15 (51.7) | 2.3 (1.7-3.7) | ||||
Coping with abortion | 26 (21.7) | 0 (0) | 21 (80.8) | 5 (19.2) | 3.2 (1.7-3.7) | ||||
Post-abortion depression | 10 (8.3) | 0 (0) | 6 (60.0) | 4 (40.0) | 2.2 (1.3-3.3) | ||||
Post-abortion syndrome | 27 (22.5) | 4 (14.8) | 7 (25.9) | 16 (59.3) | 1.7 (1.3-3.0) | ||||
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.005 | |||
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Abortion pill infertility | 19 (22.4) | 1 (5.3) | 15 (78.9) | 3 (15.8) | 3.7 (2.0-4.3) |
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Can abortion cause infertility? | 11 (12.9) | 0 (0) | 8 (72.7) | 3 (27.3) | 2.0 (1.7-3.3) | ||||
Can multiple abortions cause infertility? | 15 (17.6) | 0 (0) | 11 (73.3) | 4 (26.7) | 1.7 (1.0-2.7) | ||||
Infertility after abortion | 17 (20.0) | 1 (5.9) | 10 (58.8) | 6 (35.3) | 2.3 (1.0-3.3) | ||||
Pregnancy after abortion | 23 (27.1) | 0 (0) | 22 (95.7) | 1 (4.3) | 3.0 (2.3-3.7) |
Counts of online abortion resources by slant and slant clarity (n=316).
Our study of websites that provide information about safety of abortion or subsequent risks of depression or infertility found that overall, 35.4% (112/316) of sites had an anti-choice slant. Anti-choice sites were less trustworthy, and the clarity of their stance was also more difficult to determine. Our data also show that people seeking information about the safety and potential risks of abortion are likely to find substantial amounts of untrustworthy abortion information; the overall median trustworthiness score of these sites was 2.7 (on a scale of 1-5), with a wide range (IQR 1.7-3.7).
Our results are consistent with other examples of intentionally disseminated abortion disinformation. CPCs have an antiabortion agenda but use neutral language and advertising to appear as if they are a normal medical clinic [
We know that in the case of abortion, false or misleading information continues to play a role in public debates and government legislation. For example, Targeted Regulation of Abortion Providers (TRAP) laws, or costly and burdensome regulations aiming to restrict access to abortions by dictating how, by whom, and when abortions can be provided, are often based on false health claims but framed as protecting patient safety [
Our study results should be interpreted with the following limitations in mind. We used expert ratings to gain insight into the abortion online media ecosystem. All of our experts are engaged in abortion-related research and two-thirds of our experts are abortion providers. We recognize that non-experts may have rated and classified these same websites differently. However, our expert ratings provide a benchmark for future work that explores how non-experts perceive the information contained in these websites. We also acknowledge that trustworthiness scores could be confounded with slant and that sites with obvious anti-choice slants may have been rated with lower trustworthiness scores based on the impression of bias. However, it is difficult to blind these components from each other and we wanted to provide some kind of measure of quality for the information we encountered. We recognize that our study provides only a cross-sectional snapshot of the internet. While specific site rankings may be driven by news cycles, we believe the overall picture is unlikely to change [
Our results provide insight into the online abortion ecosystem. We find that anti-choice sites are prevalent, often hard to identify as anti-choice (difficult slant clarity), and less trustworthy than neutral and pro-choice sites. Additionally, the search terms a user chooses may play a substantial role in the quality and bias of websites they see. Our results help us understand how the internet may impact public perceptions and knowledge about the safety of abortion and potential risks of depression and infertility. Our findings suggest that web searches may lead people to perceive abortion procedures as more dangerous and riskier than they actually are.
Full list of websites and site ratings.
crisis pregnancy centers
aspiration, dilation, and curettage
dilation and evacuation
Targeted Regulation of Abortion Providers
This study was funded by The Society for Family Planning.
None declared.